Orthopedics in check

1. The University of Dodoma
School of Medicine and Dentistry (SoMD)
Orthopedics, traumatology and Neurosurgery
Polytrauma, ATLS and Triage in mass causality

2. ATLS
• A Advanced
• T Trauma
• L Life
• S Support

3. Definition
• Simultaneous diagnostic and therapeutic activities intended to
identify and treat life threatening injuries, beginning with the
most immediate.
• This focus on urgent problems is first captured by the " Golden
hour“ catch phrase and is one of the most important lessons of
ATLS.

4. Golden hour
• Injuries that threaten life during golden hour
– Airway obstruction
– Tension pneumothorax
– Open pneumothorax
– Massive hemothorax
– Cardiac temponade

5. Components
• Preparation and triage
• Primary Survey
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey
• Adjuncts to secondary survey
• Definitive care

6. Preparation
• Pre-hospital phase
– Receiving hospital is notified first.
– Send to the closest, appropriate facility.
• Hospital Phase
– Advanced planning for the trauma patient arrival.
– Method to summon extra medical assistance
– Transfer agreement with verified trauma center established.
– Protect from communicable disease.

7. • The used of the following protective devices is recommended
– Goggles
– Gloves
– Fluid-impervious gowns or aprons
– Shoes covers and fluid- impervious leggings
– Mask
– Head covering

8. Primary Survey
• A Airway
• B Breathing
• C Circulation
• D Disability (mini-neurological examination)
• E Exposure and environmental control

9. Primary Survey
• During the primary survey life threatening conditions are
identified and management is instituted SIMULTANEOUSLY

10. Airway
Always consider cervical spine injury
• Open airway
• Give oxygen
• Stabilize cervical spine

11. • Open airway
– Inspect tongue, foreign body
– Chin lift-head tilt
– Jaw thrust
– Suction
• Nasopharyngeal
• Oropharyngeal
– Intubation
• Endotracheal intubation
• Cricothyroidotomy

14. Airway adjuncts

15. Endotracheal tube

16. Intubation

17. • Indication For Definite Airway-(intubation)
– Unconscious
– GCS <8
– Severe maxillo-facial fracture
– Risk for aspiration : Bleeding/ vomiting
– Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
– Apnea : Neuromuscular paralysis/unconscious
– Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
– Severe closed head injury

18. Breathing
• Airway patency does not assure adequate ventilation
• Inspection
– Engorged neck veins
– Trachea deviation
– Chest expansion
• Symmetrical and adequate
• Percussion
• Auscultation

19. Circulation
• Control external hemorrhage
• Check for Pulse rate, blood pressure, capillary refill, extremities
• Two IV large bore cannula
• Take blood sample for investigation
• Give bolus 2 litres of warm saline
– Children 20mls/kg

20. Disability
• AVPU
• Glasgow comma score (GCS)
• Pupils
– Equal size, reactive to light
• Lateralizing signs
• Movement of all extremities
– Upper and lower limbs
• Muscle power grade

21. AVPU scale
• A : Alert
• V : Responds to Vocal stimuli
• P : Responds to Painful stimuli
• U : Unresponsive to all stimuli

22. Glasgow Coma Score (GCS)
• Eye opening (E)-4
– Spontaneous 4
– To speech 3
– To pain 2
– None 1
• Best motor response (M)-6
– Obeys commands 6
– Localizes pain 5
– Normal flexion (withdrawal) 4
– Abnormal flexion (decorticate) 3
– Extension 2
– None (flaccid) 1
• Verbal response (V)-5
– Oriented 5
– Confused conversation 4
– Inappropriate words 3
– Incomprehensible sounds 2
– None 1

23. Exposure and environmental control
• Disrobe the patient
• Log roll maintaining axial traction
– Inspect back
– DRE
• Cover patient to keep warm

24. Resuscitation
• Oxygenation and ventilation
• Shock management, intravenous lines, warmed saline or
Ringer’s lactate solution
• Management of life-threatening problems identified in the
primary survey is continued

25. Adjuncts to primary survey and resuscitation
• Re-evaluate ABCDEs
• Electro-cardiographic Monitoring
• Nasogastric tube
• Urinary catheter
– Urethral injury should be suspected if
• Blood at the penile meatus
• Perineal ecchymosis
• Blood in the scrotum
• High riding or nonpalpable prostate
• Pelvic fracture
– Adult urine output 0.5ml/kg/hr
– Pediatric urine output 1mg/kg/hr
• Pain Management

26. • Monitoring
– Ventilatory rate & ABG
– Pulse oximetry
– Blood pressure
• X-Ray & Diagnostic Studies
– C-spine, CXR, Pelvic film
– Essential x-ray should not be avoided in a pregnant patient
• FAST

27. Secondary Survey
• Does not begin until the primary survey (ABCDEs) is
completed, resuscitative effort are well established & the
patient is demonstrating normalization of vital sign.
• Head to toe examination
• Complete history and physical examination
• Reassessment of all vital signs

28. • History
– A : Allergies.
– M : Medication currently used.
– P : Past illness/ Pregnancy.
– L : Last Meal
– E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due to cold &
burn/hazardous environment?

29. • Head to toe examination
– Head
• Raccoon’s eyes
• Rhinorrhea
• Nostrils
• Maxilla
• Mandible
– C spine
• Any area of tenderness
• Engorged neck veins
• Subcutaneous emphysema
• Trachea

32. • Chest
– Visual evaluation of anterior and posterior chest
• open pneumothorax
• flail chest
– Pain , dyspnea , hypoxia
– Cardiac tamponade , tension pneumothorax
• distended neck veins
• distant heart sound

33. • Abdomen
– Closed observation and frequent reevaluation
– Unexplained hypotension
– Equivocal abdominal finding

34. • Perineum/rectum/vagina
– contusion , hematoma , laceration , urethral bleeding
– rectal examination : blood , high-riding prostate, integrity of rectal
wall , sphincter tone
– female :
• Vaginal exam.: blood , laceration
• Pregnancy test

35. • Musculoskeletal
– Inspection : contusion , deformity
– Palpation : tenderness , abnormal movement
– Pelvic Fx : ecchymosis on iliac wings , pubis , labia, scrotum , pain on
palpation of pelvic ring
– Assessment of peripheral pulses
– Patient’s back examination

36. • Adjuncts to secondary survey
– Hemodynamic status
• CT scan
• Contrast x-ray studies
• Extremitry x-ray
• Endoscopy and ultrasonography

37. • Definitive care
– After identifying the patient’s injuries
– Managing life-threatening problems
– Obtaining special studies
• Transfer
– If the patient’s injuries exceed the institution’s treatment capabilities

38. TRIAGE
 Triage is the sorting of patients based on the need for treatment
and the available resources to provide that treatment.
 Color coding –
 Red(immediate/emergency) –patient requires immediate
management
 Yellow(urgent)-treatment can be delayed for a limited period of
time
 Green (delayed) –minor injuries such that treatment may be
delayed until other patients are stable
 Black –dead or severed injuries that are not expected to survive

39. TRIAGE IN MASS CAUSUALITY
• Multiple Casualties
– Number of severity & patient do not exceed the ability of the facility.
• Mass Casualties
– number & severity of patient EXCEED the capability of the facility &
staff.

40. MANAGEMENT OF
POLYTRAUMA

41. OBJECTIVES
By the end of this presentation students should be able:
1. To explain polytrauma
2. Describe ATLS
3. Describe management approach
4. To describe Damage control surgery

42. Polytrauma definition
 MONOTRAUMA
Injury to one body region
 MULTITRAUMA
Injury to more than one body region (not exceeding
Abbreviated Injury Score (AIS)≥3 in two regions) without
systemic inflammatory response syndrome (SIRS)

43. Polytrauma definition…..
POLYTRAUMA
Injury to at least two body regions with AIS≥ 3 in conjunction
with one or more of the listed physiologic parameters:
 Hypotension (SBP ≤ 90mmHg)
 Level of consciousness (GCS ≤ 8)
 Acidosis
 Coagulopathy (INR ≥ 1.4 or aPTT≥ 40s)
 Age (≥ 70years)

44.  Polytrauma is not synonym of multiple fractures.
 Multiple fractures are purely orthopedic problem as there is involvement
of skeletal system alone.
 While in Polytrauma there is involvement of more than one system,
Like associated head/spinal injury, chest injury, abdominal or pelvic injury.
 Polytrauma is a multi-system injury and needs management by
a team of surgeons and physicians.
 Orthopaedic surgeon is one of the team member of trauma unit.
POLYTRAUMA / MULTIPLE FRACTURES

45. The systemic inflammatory response
syndrome ( SIRS)
 SIRS describes the clinical presentation of patients with
systemic activation of the inflammatory response from any
underlying cause( Infection or trauma)
 As a consequence of SIRS, patients may develop multiple
organ dysfunction syndrome( MODS) and acute respiratory
distress syndrome (ARDS).
 The degree of SIRS following trauma is proportional to the
severity of injury.

46. Trauma scoring system
Purpose of scoring systems
 Appropriate triage and classification of trauma patients
 Predict outcomes (for patient and family counseling)
 Quality assurance
 Research
 – extremely useful for the study of outcomes

47. Classification Of Scoring Systems In
Trauma
Physiological Scores:
 Glasgow Coma Scale (GCS)
 Revised Trauma Score (RTS)
 Paediatric Trauma Score
 Acute Physiology and Chronic Health
Evaluation (APACHE)
 Systemic Inflammatory Response
Syndrome Score (SIRS)

48. Classification Of Scoring Systems In
Trauma……
Anatomical Scores:
 Abbreviated Injury Scale (AIS)
 Injury Severity Score (ISS)
 Anatomic Profile (AP)
 Penetrating Abdominal Trauma
Index (PATI)

49. Glasgow Coma Score
 The GCS is scored between 3 and 15, 3
being the worst, and 15 the best.
GCS is composed of three parameters :
 – Best Eye Response (4)
 – Best Verbal Response (5)
 – Best Motor Response (6)

50. Injury Severity Score (ISS)
The Injury Severity Score (ISS) is an established medical
score to assess
trauma severity.
 It correlates with mortality, morbidity and
hospitalization time after trauma.

51. Injury Severity Score (ISS)…..
 To calculate an ISS for an injured person, the
body is divided into six ISS body regions:
– Head or neck - including cervical spine
– Face - including the facial skeleton, nose, mouth, eyes and
ears
– Chest - thoracic spine and diaphragm
– Abdomen or pelvic contents - abdominal organs and lumbar
spine
– Extremities or pelvic girdle - pelvic skeleton

52. Injury Severity Score (ISS)…..
 Calculation is based upon the Abbreviated
Injury Scale (AIS) grades
0 - no injury
1 - minor
2 – moderate
3 - severe (not life-threatening)
4 - severe (life-threatening, survival probable)
5 - severe (critical, survival uncertain)
6 - maximal, possibly fatal

53. Injury Severity Score (ISS)…..
 ISS = sum of squares for the highest
 AIS grades in the three most severely
injured ISS body regions
 ISS = A2 + B2 + C2
 where A, B, C are the AIS scores of the
three most severely injured ISS body regions

54. Injury Severity Score (ISS)…..
 scores range from 1 to 75
 If an injury is assigned an AIS of 6
(unsurvivable injury), the ISS score is
automatically assigned to 75

56. Every team must have a final decision maker:
Management -TEAM APPROACH
Anesthetist.
General surgeon
Neurosurgeon
Orthopedic surgeon
A TEAM consists of:

57. Damage control surgery
 Damage control surgery (DCS) is a form of surgery
typically by trauma surgeons utilized in severe unstable
injuries.
 This form of surgery puts more emphasis on
preventing the triad of death, rather than
correcting the anatomy

58. Trauma triad of death
 Massive hemorrhage lead to :
 1. Hypothermia
 2. Metabolic acidosis
 3. Coagulopathy

60. Damage Control Surgery
(“STAGED LAPROTOMY”)
•Arrest bleeding , and the resulting coagulopathy.
• Limit contamination and the sequelae .
•Close the abdomen to limit heat and fluid loss,
and to protect viscera.
Damage control orthopaedics
1st stage temporary stabilisation of #
2nd stage resuscitation and optimisation
3rd stage definitive fracture fixation
•External fixator is most commonly used for temporary stabilisation
•Change to definitive # fixation is done latter